Transcript Intern Survival Guide - Pediatric Web Portal

Intern Survival Guide
Newborn Nursery
Outline
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Introduction
Schedules
Where things are
When things happen
Pre-rounding:
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Newborn Exam
Admissions
Progress Notes
Discharges
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Orders
Transfers to/from NICU
Attending Rounds
Family Rounds
Important People
Medical Students
Weekend Call
So you’re starting the newborn
nursery…
The newborn nursery is located in the new mother-baby ward of
the hospital. To get there, hang a right at Starbucks and take
the elevator to the 6th floor. You’ll need your ID at practically
every entrance so don’t forget it!
 The nursery itself is located about halfway down the hallway.
The front door is on the north side (higher numbers); the door
closest to where the resident hangs out is on the south side
(lower numbers). Only the south entrance requires your ID to
let you in.
 When the census is low, most moms (and babies) reside on the
6th floor. There is, however, overflow to the 5th floor (usually
antepartum), so pay attention to where your patients actually
are.
 Dress code is business attire ± white coat. If you’re on over the
weekend, you may wear scrubs.
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Schedules
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As the newborn resident, you’ll be working from whenever you arrive in the
morning (more on that later) until 5pm.
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You will work one weekend day for three weekends with one golden
weekend.
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To check the Newborn schedule, go to New Innovations  Scheduling
Assignment  Monthly Schedule 
Schedule Access
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To access your personal schedule, go to:
– New Innovations:
https://rms1.newinnov.com/Login/Login.aspx
– After logging in, hit
– View:
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Take a couple of hours one day and just browse
through new innovations. It does take some
getting used to.
Where Things Are: Babies and
Accessories
Babies themselves will either be in the nursery or
in with their moms. If you need to examine a
baby and the baby is not in the nursery, the
easiest thing to do is to go into the mom’s room
and examine the baby there. You can also bring
the baby back to the nursery with you or (very
nicely!) ask the floor nurse to bring the baby to
you.
 Bassinettes are stocked with pretty much
everything you need: diapers, wipes, receiving
blankets, etc.
 Ophthalmoscopes are located here and there
around the two nurseries for easy access.
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Where Things Are: Charts
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Blue Baby Charts
– Located in the nursery during the early morning hours and out on their
appropriate floors after rounds.
– Things you will find in the charts that are important to you, in order from front
to back:
 NBN report sheet – when the nurse from L&D delivers the baby to the nursery,
the newborn nurse takes notes on this sheet. Provides a summary of
information.
 Inpatient Admitting Face Sheet – with insurance information
 Assessments/H&P section
– NB nursery summary sheet – the infamous “columns” sheet in duplicate. Serves as
your history, admission and discharge physicals.
– Admission/Delivery Summary – usually put in the day after admission, details
information printed from the CIS system.
– Birth Report (sometimes)
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Physician Orders – where discharge orders are written.
Consents – HepB and circumcision.
Progress Notes
Report of Operation – Birth report will be found here if not in the H&P section
Nursing Records – NICU/NBN nursing admission sheet
Where Things Are: Charts
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Red Mom Charts
– Located in L&D with mom immediately after delivery.
Comes over with mom when she is taken to her room.
– There are 2 things in this chart important to you:
 Prenatal Records – usually clipped to the front of
the chart or in the H&P sections
 Admission Note – in the H&P section. Will provide
a wealth of information, including the number of
antenatal visits.
– HIV, GBS, HepB and blood type will be written
in a number of places. RPR and DAT are
usually done when the mom is admitted, so
check mom’s Powerchart for those.
Where Things Are: Charts
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Yellow Bedside Charts
– Clipped to the baby’s bassinette.
– Record of:
 Day of life
 Birth weight
 Daily weight and change
–  Tip: Nurses weigh the babies at 5pm each night. If the new
day’s flow sheet is missing a weight, check the flow sheet from the
day before. It’s often recorded in a column there.
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Vital signs
Voids and stools
Feedings
NAS scoring (if applicable)
Where Things Are: Paperwork
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Blank Flow Sheets/Progress Notes
– Newborn nursery is a lot of paperwork. Paperwork has its place in
medical education - not only does it keep you on top of what is going on
with your patient, but you learn the very important skill of proper
documentation and time-management.
– You will find most necessary documentation in the filing cabinet near the
resident’s table. From top to bottom:
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Growth charts
Admission/Progress flow sheets
Newborn Admission Note*
Progress notes
Bilirubin curves
Attending flow sheets*
Resident Binder
– Big, black binder that houses flow sheets in three sections (in order of
priority):
 Discharges
 New patients
 Interim patients
*attending-only paperwork
When Things Happen
Daily
~ 6am
Get sign-out from night resident
Prior to 9:30am:
See all babies, do all paperwork
9:30am:
Attending Rounds
Afternoon
Make clinic appointments, mommy rounds
Throughout the day:
New admissions, work, etc.
5pm
Sign-out to night resident.
*Note – When you are on newborn, you do not go to morning report but you DO
attend Grand Rounds and Wednesday lectures.
Pre-Rounding
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Your arrival time each day to the nursery should be based upon how
many patients are on your census (at our busiest, we can get up to
25-30), how comfortable you are with the paperwork and how well
you can manage your time. In general:
– If you are the only person in the nursery or your medical students are
very new, you should arrive between 5:30am – 6:00am.
– If you have seasoned medical students or are lucky enough to have
another MD in the nursery with you (another intern or a family medicine
resident), you should get here between 6:00am and 6:30am, 7am at
the latest.
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The first thing you should do when you hit the nursery is scrub,
surgical style, at one of the sinks. Stay on the good side of the
nurses. Trust us.
Next, print two copies of the census (hit task  print  print) from
PowerChart. One is for you, one is for the attending. Take a big,
black marker and cross off any babies who aren’t staff (see next
slide).
Staff Babies
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Hospitalists
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Maribeth Chitkara
Rachel Boykan
Carolyn Milana
Lisa Wilks-Gallo
Clinic Attendings
– Tech Park
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Robyn Blair
Leslie Quinn
Lycia Ryder
Taranjeet Ahuja
– East Moriches
 Susan Walker
 Tracy Down
 Rosa Cataldo
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More Clinics
– Patchogue
 Cathy Coleman
 Fred Reindl
 Robyn Labarca
– Islip
 Liliana Tique
– Southhold
 Nancy Pearson
– Riverhead
 Ann Hansen
Pre-Rounding
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Note on your census which babies need to be admitted, which ones you
think should be discharged and which ones are interim.
– An anticipated discharge list (with total and direct bili levels) will be hanging up
on a clipboard to your right as you walk in.
– Compare the anticipated discharges with patients you think should be discharged
home (day 2 NSVD, day 3 CS). Anyone missing from the anticipated list could
still be discharged. Check with the floor nurses – or better yet, moms
themselves – to find out.
Organize yourself using your census as a to-do list. (Appendix 1)
 Examine all of the babies, discharges with priority.
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–  Tip: If the census is manageable, see all the babies in the nursery first.
Then, take your black binder and ophthalmoscope out onto the floor and see the
babies in their mothers’ rooms.
– If the census is crazy, ask the nurses very nicely if you could please have, at the
very least, the discharges brought to you.
– The night newborn resident should have done all of the admissions overnight,
but you should still examine all of the new babies in the morning if you have
time to do so (especially if they were admitted before midnight).
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Before or after your exam, note on your flow sheet the date, DOL, weight,
change from birth weight, feeds, voids, stools and physical exam.
The Newborn Exam
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The Newborn Exam:
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General Appearance: alert, active, NAD
Skin
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Look at color – pink, cyanotic, acrocyanotic
Feel for temperature – is baby cold, or warm
Look for any rashes
Nevi (red, brown, blue), stork bites on back of
neck…
Look for Mongolian spots
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Are nails short or long
Are they stained with meconium
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Feel for fontanelles
Feel for caput succedaneum – crosses sutures
Feel for cephalohematoma – does not cross
sutures
Look for any bruising, stork bites, nevi
Look for molding
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Eyes
Ears
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Check for red reflex
Look for red nevi on eyelids
Look for conjunctival hemorrhage
Look for cataracts by placing light from the side
Look for any discharge from the eye –
conjunctivitis?
Look for patency
Look for any tags
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Check for cleft palate and suck reflex by placing
gloved finger in the mouth and feeling for the
palate.
Look for Epstein Pearls (white lesions)
Uvula – normal versus bifid
Symmetry when crying
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Supple?
Feel for nodes or masses
Check clavicles by feeling for fractures/ crepitus
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CTAB good aeration vs otherwise
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Listen with bell
RRR, nl S1 and S2, any murmurs? Good
pulses? Cyanosis?
Neck
Lungs
Heart
Abdomen
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Check for patency by placing one finger
on one nare and listening for air on the
other.
Mouth
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Head
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Nose
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Nails
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Softness
Diastesis rectus (gap where rectus muscles
should be) with hernia?
Bowel sounds present?
Any masses or HSM? Feel for liver edge.
Cord: 3 vessels by exam or report
The Newborn Exam
– Genitalia
 Male
– Circumcision?
– Scrotal sacs for descended testes
– Patency of anus
 Female
– Check labia
– Check for any vaginal tags
– Patency of anus
– Extremities/Back
 Check for symmetry
 Feel for any lymph nodes under armpits
 Check for hip dislocation:
– Ortolani: Grab knee, placing 4th and 5th fingers on hips, then external rotation (O =
OUT)
– Barlow: Grab knee and press back down with fingers in the same position. (B = BACK)
 Check for hip laxity
 Turn the baby over and check for:
– Tufts of hair
– Angle and symmetry of spine
– Dimpling
 Brachial/Femoral pulses
– Neurologic
 Tone: Lift baby from under the arms - does baby slip between your fingers?
 Check for all 4 reflexes: grasp, suck, moro, and rooting
 Check for tremors
Pre-Rounding Paperwork:
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After examining all of the babies, gather all
of the charts and sit down to get all of your
paperwork done, discharges again with
priority.
The night newborn resident should have
done all overnight admissions, but make sure
all of the information on your flow sheet and
summary sheet is complete.
The following slides will detail the necessary
paperwork for admissions, discharges and
interim patients.
Admissions
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To keep on top of admissions, refresh your
census frequently, keep your ears open for calls
from L&D and listen for the printer (it will print
lots of pages with new admits).
When the baby first gets here, listen to the L&D
nurse sign-out to the nursery nurse. If you miss
it, don’t worry. All the initial information goes on
the first sheet in the chart, the Newborn Nursery
Report Sheet.
Double check which pediatrician is written on the
green Newborn Physician Information sheet that
comes with the baby. If it’s not staff, it’s not
your admission, no matter what the computer
says. If it is, roll on.
The nurse will take the baby to the warmer and
do her admission. Let her chart everything and
bathe the baby. Her vitals and physical will go in
the Nursing Records section. Once the chart is
complete and the baby is nice and clean, you can
start your admission.
Comb the chart for all the information necessary
to fill out your admission flow sheet. Remember,
maternal RPR and DAT will be in the computer.
Do your exam and fill the PE section.
Transcribe all of the information you have onto
the blank Newborn Admission Summary
Sheet found in the H&P section. Don’t forget to
put the HIV and GBS status down by PNLs.
Admissions (Continued)
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Admission Orders
– Some orders will be put in by the L&D nurse.
– Your admission orders will be found in your pediatric folder under
“Newborn Nursery Admission Power Plan.” Everything will be checked
for you (except for social work/lacatation consults). Initiate and sign.
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Mom’s Arrival
– As you might have noticed, some things are missing from your admit
flow sheet/summary sheet. All of those things will be neatly filled in
once mom arrives at postpartum.
– Mom will give consent/refuse HepB
– Mom’s chart is a wealth of information:
 Her medical history
 Her prenatal labs
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Notifying the Attending
– Unless you are unsure about a plan of action, there is no need to notify
an attending about an admission.
– The attendings will see the new babies during evening rounds or the
next morning.
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The H&P and exam must be filled out within 24 hours of birth time.
The Interim Babies
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For babies that are neither
coming nor going, fill out
the back of the
admission/interim flow
sheet for that day.
Grab a blank “NP/MD”
progress note and fill it out.
The attending will co-sign
your note and/or write her
own.
Because the attending must
write a note on all of the
interim babies, they are last
on your priority list. If
there is a huge number on
the census and you don’t
get to them, don’t worry.
Discharges
Discharges are the number one priority in the morning.
Double-check the anticipated discharge list and see everyone.
 Fill out the discharge weight, date and time of discharge
exam and the discharge columns on the summary sheet.
Don’t forget:
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– Date and hour of life of T/D bili (drawn the night before at 4am),
written in the lower left box
– Recording any labs done
– Anything else that you would want to know if you were the
primary pediatrician
Fill out the discharge orders (located in the “physician orders”
section of the baby’s chart). Note the date and time of their
follow-up appointment and what the baby should be feeding.
 After the attending sees the patient and gives his or her
blessing, write discharge orders on PowerChart.
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Transfers to/from NICU
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Transfers to NICU can be done at any time.
– If you are especially worried about a baby, take the baby over first,
then talk to someone.
 This is true of notifying the attending, as well.
 Always go with the baby if they are transferred to NICU.
 When you get there, sign-out to the resident (and fellow, if necessary).
– If you just want the baby looked at and assessed by a NICU fellow,
have one paged.
– As with any transfer, make sure to write a detailed transfer note.
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Transfers from NICU
– Babies admitted with gestations 34-35 wks may be transferred to NBN
after 24hrs of cardio-respiratory monitoring.
– Infants > 35 weeks may go up anytime after determined to be stable.
– Newborns with any type of physiologic instability/delayed transition may
be transferred to NBN after consultation with the accepting physician.
– Transfer Orders from NICU should include the name of physician
accepting transfer and any orders that should be continued, i.e.,
feeding, medications, etc.
– On admission to Newborn, fill out the H&P admission column. Gather
all the information that you would with any other admission.
Orders
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All order writing is now done electronically through our CPOE system.
Please refer to your PowerChart training for more specific
instructions.
You should notify the patient’s nurse of any new orders, especially if
the order is written as STAT.
 Tips and Tricks
– Admission orders are found in the “pediatric” folder. The “Newborn
Nursery Admission Power Plan” will have everything you need to admit a
baby.
– If HepB was given, it should be found under the baby’s MAR.
– To find out if the mom was given appropriate antibiotics, check her MAR.
– If you have a withdrawal baby on morphine and it is time for a dose
change, remember that the pharmacy sometimes takes forever and a day
to get drugs where they need to be.
 If you are going from .12mg to .09mg Q4H, and the baby is due to receive a
.12mg dose at 8am, let the baby get it.
 After the baby receives that dose, cancel the order in PowerChart and put in the
new dose (.09mg), first dose to be given at 12pm.
 Make sure to call the pharmacy and let them know you’ve made this change. You
should get the new dose in time for the 12pm administration, but no promises.
Attending Rounds
Attending rounds are generally bedside,
incorporating presentations with teaching.
 Usually begin at around 9:30am, though this
is attending dependent.
 Each attending will let you know their
rounding preferences and their expectations
of you and your medical students.
 Length of rounds is obviously dependent on
the census. When the census ranges from
10-15, you will likely be done by noon. This
gives you plenty of time for lunch, new
admissions and afternoon mommy rounds.
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Mommy rounds
In the afternoon, you and your medical students
should make rounds to see all of the families on the
floor.
 General questions to ask:
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– Do they have any questions or concerns?
– Breast/bottle feeding? Any problems with breastfeeding?
– Who will be the baby’s pediatrician? If they do not have
one, are they interested in one of our clinic pediatricians?
– Who is the insurance provider for the baby? (Make sure
we take their insurance if they want one of our doctors!)
Note the patient’s PMD and insurance on your
admission flow sheet.
 Address any and all concerns the parents have.
Reassure them that there is a pediatrician on at all
times and their baby will be looked at every day.
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Anticipatory Guidance
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Rectal thermometers only in first 2 months of life.
– Any temperature below 97 or above 100.4 is an emergency.
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Back to Sleep (SIDS campaign).
– Baby sleeps alone in the crib on his/her back, no pillows or
stuffed animals, reducing the risk of SIDS.
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Carseats
– Parents must have one before leaving the hospital
– Current AAP recommendations as of April 2009 are to be rearfacing until age 2 or outgrows manufacturer’s limits for weight
and height.
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Smoking
Address any other concerns the family may have, ie
immunizations, jaundice, etc.
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Note that you’ve given anticipatory guidance somewhere on
your flow sheet.
Important People
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Lisa Clark (beeper 4-5859)
– Newborn Nurse Practitioner
– Lisa helps to “run” the nursery by assisting the team with
any number of tasks. She spends considerable amount of
time with the many psychosocial issues we have in the
nursery.
– It should not be assumed by any member of the newborn
team that Lisa will be available to assist with morning
rounds or pre-rounding work.
– Lisa has 25 years of newborn experience and is also our
resident neonatal withdrawal expert. If you don’t know
something, chances are, Lisa does. She is an invaluable
resource.
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Kathy Vanderventer – lactation consultant
Darlene/Stephanie – social workers
Medical Students
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All students assigned are to collect information,
examine and chart on infants.
Depending on the ability to complete tasks, the
average assignment is 3-5 patients.
Medical students should also assist with new
afternoon admissions.
All assigned patients are under the supervision of
the residents and nursery attending. All findings
admission/ discharge chart notes must be
completed in time to attend AM rounds.
It can get busy, but try to make the time that the
students spend in the nursery worthwhile. Teach
as much as you can, even if it’s only pearls of
wisdom here and there. They’ll appreciate it.
Assignments
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www.Breastfeedingbasics.org
– Click “Register”, then click “Students enroll in your course”. Then type in Stony Brook
and click “Find”. Then register and complete the course. (You may skip the
International Section.)
– The scores of this course will be sent to Dr. Guralnick.
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Newborn Nursery Exam
– https://ezexam.som.sunysb.edu/q4/perception.dll
– As part of your newborn nursery rotation, all interns must take and pass the online
exam that is now available. All the questions are based on the required readings
on pedsportal.
– The test will contain approximately 13 random questions from a large bank of board
style questions. If you do not achieve 85% or better, you will need to retake the
exam until you pass. You will not pass the rotation if you do not pass the exam.
– You will need an access code that will only work for a limited period of time after
your rotation ends, therefore it is critical that you take the exam in a timely
fashion during the last week of your rotation.
– Please e-mail or see Elaine for your individual access code.
Schedule time to observe a Lactation Consultant interact with a
mother/baby.
 Observe one hearing evaluation.
 Perform an observed physical exam.
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Required Readings
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Week 1:
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Week 2:
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– Hypoglycemia protocol
– Clinical Practice
Guideline Management
of GBS in the Neonates
– Summary sheet on
Hepatitis B, Hepatitis C,
HIV, Syphillis, and TB
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– Neonatal Jaundice
– Respiratory Disorders of
the Newborn
– TORCH infections
– Hepatitis B
Week 3:
– Presentation of
Congenital Heart Disease
in the Neonate and
Young Infant
– Fetal Hydronephrosis
– Development Hip
Dysplasia
Week 4:
– Brachial Plexus Injury
– Sudden Infant Death
Syndrome
– Newborn Hearing Screen
Weekend Call
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Weekends are structured exactly like weekdays.
Time your arrival depending on the census, and
take into consideration that neither Lisa nor the
medical students are available over the weekend.
Most attendings will get in early, see babies by
themselves, then sit down to round. (However, this
is extremely attending-dependent, so stay flexible!)
Make sure that you have all your paperwork done.
 Try to get all clinic appointments scheduled on
Friday and Saturday. Clinics are closed on Sundays.
Appendix 1
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How you organize yourself is up to you, but most interns will use their
census as a to-do list.